Shorter operative, recovery time but more pain with vaginal vs. laparoscopic hysterectomy

Key takeaways:

• Vaginal vs. laparoscopic hysterectomy was linked to less operative and recovery time but greater pain on surgery day.
• Vaginal hysterectomy resulted in less blood loss and postoperative urinary tract infection.

Women who had vaginal vs. laparoscopic hysterectomy had shorter total operative and recovery time but reported worse postoperative pain on the day of surgery, according to a systematic review published in Obstetrics & Gynecology.

“While both vaginal and laparoscopic approaches are both great minimally invasive approaches, as more data is now available, we are starting to see some advantages to vaginal hysterectomy,” Greg J. Marchand, MD, FICS, FACS, FACOG, surgical technique inventor, teaching surgeon and accredited master surgeon at the Marchand Institute for Minimally Invasive Surgery, told Healio.

Marchand and colleagues conducted an online search of PubMed, Scopus, Web of Science, ClinicalTrials.gov and the Cochrane Library from 2000 to February 2023. Researchers identified 23 randomized controlled trials with 2,408 women that compared vaginal and laparoscopic hysterectomies for benign gynecologic conditions for the final systematic review, of which 22 were included in the meta-analysis.

Across the studies, 1,105 women had vaginal hysterectomies and 1,303 had laparoscopic hysterectomies. The vaginal hysterectomy group experienced lower blood loss (mean difference, –68 mL; 95% CI, –104.29 to –31.7) and postoperative urinary tract infection (OR = 1.22; 95% CI, 0.6-2.46) rates compared with the laparoscopic hysterectomy group.

Vaginal hysterectomy was associated with 34.94 minutes less operative time, 2.45 days less of recovery time and greater reported postoperative pain on the surgery day as measured by visual analog pain scale scores (mean difference, 1.66; 95% CI, 0.19-3.13) compared with laparoscopic hysterectomy.

Conversion to laparotomy, visceral organ damage or wound dehiscence was uncommon in either the vaginal or laparoscopic hysterectomy groups.

“I don't think any surgeons are going to completely change the way they do hysterectomies because of this one study, but it's going to cause a lot of people, especially residency program directors and fellowship program directors to consider what goes into medical training,” Marchand said.

According to Marchand, it may be worthwhile to increase vaginal hysterectomy training in residency to improve long-term outcomes.

“We need more research on where these differences come from and how surgeons can improve in the future. While this study included clinical trials, it would be wonderful if we could further breakdown which exact procedures were the most effective or safest,” Marchand said. “Also, it would be great to know more about the learning curve for these procedures. For example, we can't extrapolate yet if the risks are higher for a new surgeon performing a vaginal hysterectomy or laparoscopic, or how the results change in the hands of a very experienced surgeon.”

For more information:

Greg J. Marchand, MD, FICS, FACS, FACOG, can be reached at marchandinstitute.org.